WPC >pЪCȩaVFO뱐[W/Ҽ4(Yyu teĞ&$l71Nk%R:ztYxrAP 3są 9SNq ſR봪QW*jz {sñb]~M [-F_9AJ@hz5 ,zwHNQ+b>GS&""E ~3@?2F <{kvvi?KY][r(n`S/!6N'WٙA )dZCZf(;MAϭ! .U3uկ?2`(7H@C\vQh/ԎG 4SX F Z ؙoPc:G!H~^Ϥx ~X$rn9RHϒp_wD$U&>6 0  0< 0 UB 0 U, D+ C 03 U0 < 0 0( AMoH@o@o@em 0}#3UN %BMH(LNt^ vw4 m\  `&Times New Roman' PATIENT REGISTRATION FORM Shepard0Shepard .   6g `4Heading 1XXX 8.,,X <DL!T$&8   A7,,4 <DL!T$&A <:Default Para. ,Title999W*jp`*Bookman Old StyleW   &,,!T$&&  J@,4 <DL!T$&JS\  `&Times New RomanS *jp`*Bookman Old Style< :Document MapA $TahomaAC 4$X ddCA $TahomaA  7 (X7S\  `&Times New RomanS  $Tahoma'dxddd8:g 6Block Text      ?!     D:,4 <DL!T$&D*jp`Garamond Level 1 Level 2 Level 3 Level 4 Level 5(2;$ 3!,,..      3jXX3j3j  ($  A<< cWPCx 1x 1x 1 Wx 1}.3 g`w<7@ ?  +++++++@?  '      3jXXe IherebyauthorizeMountainsideInternalMedicinereleasetoanycompanywhichhasissuedtomemedical +($0 orhospitalizationinsurance,allinformationregardingtreatmentbysaiddoctorandIfurtherassigntosaid (f%1 doctorallmedicalandsurgicalbenefitspayabletohim/herundersaidpolicy.Ifurtheragreetopaysaid )%&2 doctorforanychargesforprofessionalservicesnotcoveredbysuchpolicy.MountainsideInternal h*&3 MedicinemayaccessanypartofmyrecordsfromSt.Peter'sHospital(includingtreatmentforalcoholor '+'4 drugabuse)forcontinuityofcarepurposesand/orfortheadjudicationofallclaimsrelatingtopaymentof +b(5 servicesconnectedwiththehospitalizationasprovidedbytheHealthCareInformationAct.Recordsmay ,!)6 beaccessedinhardcopyorbycomputer.  ?!'  XeX3j   6,,L!T$&,,?n&>6 Signature  Date #.*8 W7,,4 <DL!T$&,,LX&WVFBx \ynp{o@XE, /ynyn /nVFBx \rpv@XEe/rre/3jXXe  /+9